Endobronchial actinomycosis associated with aspiration of a shirt button: A 30-year latency
Article Outline
Summary
We report a case of foreign body induced endobronchial actinomycosis secondary to a shirt button aspirated 30 years previously. Radiological and bronchoscopic appearances mimicked that of lung cancer. However pathology revealed gram-positive anaerobic infection with actinomycosis, which was successfully treated with antibiotics. Previously reported incidences of this rare presentation have been due to organic material, usually food matter. This case illustrates the importance of evaluating episodes of foreign body aspiration and also considering actinomycosis in the differential diagnosis of endobronchial mass. Repeating bronchoscopy after treatment and clinical improvement revealed a reduction in the size of the endoluminal mass and is therefore essential to exclude a foreign body or tumour not seen on initial assessment.
Keywords: Actinomycosis, Lung neoplasm, Foreign body, Aspiration, Bronchoscopy
Case originality
The few previously reported incidences of this rare presentation have been caused by organic material, usually food matter. This case is unique, because the presentation of actinomycosis is secondary to a shirt button aspiration. The latency since aspiration is also 30 years which is exceptional. The case illustrates the importance of evaluating episodes of foreign body aspiration and also considering actinomycosis in the differential diagnosis of endobronchial mass. Repeating bronchoscopy is essential to exclude a foreign body or tumour not seen on initial assessment.
Case report
A 62-year old Caucasian lady with a history of asthma presented to outpatients via the two-week urgent referral pathway. She gave a four-week history of increasing breathlessness on exertion and cough productive of purulent sputum. She denied any haemoptysis, chest pain or weight loss but complained of episodic sweating three times per week. She also had a previous history of type two Diabetes Mellitus, gastro-oesophageal reflux disease, hypertension and hypercholesterolaemia. She had been a very occasional smoker and drank six units of alcohol per week. On examination she was noted to have angular stomatitis and dental caries. Chest examination revealed dullness to percussion and reduced breath sounds at the right lung base. There was no wheeze, nor clubbing or lymphadenopathy. Heart sounds were normal. Peak expiratory flow was reduced at 250
L/min (patient's best: 400L/min). She was afebrile, with a pulse of 126 beats per minute and oxygen saturations of 96 percent on room air. White blood cell count was elevated at 12.4×109/L and neutrophil count raised at 9.59×109/L. Chest radiograph revealed right lower zone consolidation with evidence of collapse (Fig. 1A). Subsequent contrast enhanced computerised tomography (Fig. 1B) demonstrated occlusion of bronchus intermedius with collapse of the right middle lobe and para-tracheal and sub-carinal lymphadenopathy. Initial fibre-optic bronchoscopy revealed subtotal obstruction of bronchus intermedius, with infiltration by possible tumour. Histology revealed inflammatory changes, with squamous metaplasia. She went on to have a rigid bronchoscopy under general anaesthetic. A grey tumour-like mass in bronchus intermedius was noted. Biopsy histology revealed chronically inflamed mucosa, calcified foreign material and filamentous gram-positive organisms resembling actinomyces. Furthermore, cervical mediastinoscopy revealed inflammatory change only in the pretracheal lymph nodes. The patient was given oral co-amoxiclav 1250mg bd for two weeks and then 625mg tds for four weeks and made good clinical improvement with radiological resolution. She was also referred to the maxillofacial unit for dental review. Further bronchoscopy at four months revealed a partially obstructing lesion at bronchus intermedius that was difficult to biopsy (Fig. 1C). Grasping forceps eventually removed a small blue button impacted side-on with surrounding inflammatory changes (Fig. 1D). On further questioning the patient reported inhaling a small button while sewing it on to her son's school shirt. She had consulted an ENT consultant at the same hospital in 1977 where an entry in the medical notes reads: “the patient presents having swallowed a shirt button and can feel something stuck in her throat… I feel it very unlikely that the button is retained”.
Figure 1
A. Chest radiograph showing right lower lobe consolidation and collapse. B. Computerised tomography showing broncholith and subtotal obstruction of bronchus intermedius. C. Bronchoscopic appearance at level of bronchus intermedius, showing impacted button. D. Button immediately after extraction.
Discussion
Actinomycosis is a chronic suppurative pulmonary infection usually caused by Actinomyces Israelii which is present in the oropharynx of humans. Pulmonary infection with actinomyces species is uncommon, but usually results from aspiration of oropharyngeal secretions in those with chronic dental infection, extension from cervicofacial infection or haematogenous spread from a distant source.1 Pulmonary infection manifests as unresolving pneumonia, pulmonary infiltration2 or endobronchial pseudotumour, often a calcified nodule (broncholith).3 Foreign body associated endobronchial actinomycosis is rare and bronchial infection is thought to result from inhalation of actinomyces-contaminated material.4, 5, 6, 7, 8 Recent review of reported cases of foreign body actinomycosis showed that the foreign bodies are usually organic, including meat and fish bones, teeth and a seed, with one reported case of inorganic foreign body inhalation – a dental crown.4 In our patient the button is likely to have become a host for subsequent actinomyces species contamination once the patient had developed poor dentition. This would explain the 30-year latency period. The fact that the button was impacted side-on in the bronchus intermedius meant that the foreign body was retained without significant bronchial obstruction. Therefore the patient remained asymptomatic until infection ensued. Mucosal breaches secondary to foreign body impaction must occur for actinomyces species to colonise and cause a marked granulomatous inflammatory reaction.3, 4 The commonest bronchoscopic finding is an endobronchial mass9 that is difficult to differentiate macroscopically from a bronchial tumour. The presence of sulphur granules on biopsy is highly suggestive of actinomycosis4 and additional tests will reveal a non acid-fast filamentous organism with a positive gram stain.10 In the review by Chouabe et al. a foreign body was not found on initial bronchoscopy in 55% of previous cases.4 This was also the case with our patient. Repeat bronchoscopy after treatment and clinical improvement revealed a reduction in the size of the endoluminal mass and is therefore essential to exclude a foreign body or tumour missed on initial assessment. Endobronchial actinomycosis must be considered in the differential diagnosis of a biopsy negative endobronchial tumour, and as a complication of foreign body inhalation. Careful evaluation of patients' oral and dental hygiene, establishing previous episodes of aspiration, even after many years, and the presence of broncholithic radiological lesions will all aid diagnosis.
Competing interests
The authors have no competing interests to disclose.
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PII: S1755-0017(08)00089-4
doi:10.1016/j.rmedc.2008.10.018
© 2008 Elsevier Ltd. All rights reserved.
